Sunday, May 7, 2017

How does social class
prejudice reveal itself in public health? Among conservatives it might be the
attitude that low income people deserve to be sicker, and we don’t need to help
them, because they are lazy. Liberals have their attitudes, too. For example,
“we are experts and know best what you poor folks need,” although that, too, is
often not true. I’ve been thinking about this in connection with public health
programs that just don’t work the way they should: transportation benefits that
people have too much trouble using, mental health coverage that is inadequate
for the problems many people face, cuts to programs that have worked well; and
yet public health tolerates these situations! Why? Let’s explore one concrete
example how social class works in public health: efforts to reduce tobacco
smoking.

Tobacco is the drug of choice
for low income Americans. For example in Gratiot County we found that 31
percent of adults who earn $20,000 or less smoke compared to 9 percent of
adults who earn $75,000 or more. Twenty-nine percent of mothers smoked while
pregnant! This is a really big deal. In another blogpost I wrote about how heart
disease deaths are increasing in rural Michigan.

Today, public health in
Michigan has two favorite ways to try to help people quit. First, you can sign
up to get friendly text messages that encourage you to keep trying; second,
Michigan like other states has jacked up taxes on cigarettes to high levels
(not high enough for some) in hopes of making smoking too expensive. You can
find lots of research that says these two approaches are effective in getting
people to quit, but they aren’t, at least among low income people. The reason
public health says texts and taxes get people to quit smoking is because that’s
all we’ve got left. Our general fund budgets are far less likely to support
tobacco cessation programs than they once were, and health insurance, including
Medicaid, doesn’t reimburse enough for us to support cessation programs by
billing insurances—but still, we want to be able to say we’re doing something.

But not everyone agrees. In “Poor Smokers, Poor Quitters, and Cigarette
Tax Regressivity” appearing in American Journal of Public Health, Dahlia
Remler found, “cigarette taxes heavily burden poor smokers who do not quit, no
matter how tax burden is assessed.” In another study in the Journal of Policy
Analysis and Management, Remler said, “Very high cigarette taxes, however, have
a dirty little secret: their regressivity. Overwhelmingly and increasingly,
smokers are concentrated among the poor. Moreover, our era of rising cigarette
taxes is also an era of dramatically rising income inequality and possibly
lower purchasing power for the poor.”

The
public health community has rallied behind the taxes. The Campaign for Tobacco
Free Kids says, somewhat snarkily, “it is smoking itself and its health harms
that are hurting the lower-income population,” not the taxes. Therefore the
Campaign is not responsible for the harms of the taxes. The social class bias
in this attitude is somewhat breathtaking. You can almost hear someone huffing
“if they are too stupid to quit, screw them.” The Campaign is a left-leaning
progressive public health organization, but here, their attitudes are similar,
for example, to Republicans in the House of Representatives who think it is OK
to get rid of health care benefits for low income people because they “made bad
choices.”

But evidence is mounting that
tobacco taxes are harmful to the poor. Katherine T. Hirono and Katherine Smith
published a review of the literature and concluded
that “very large cigarette tax increases unintentionally harm the most
vulnerable in society: smokers who are homeless, very low income, and/or suffer
from mental illness… Low-income smokers who either can't or won't kick the
habit following large tobacco tax increases face increased financial hardship,
and so do their families.”

But surely low income people
don’t give up food or other necessities just to keep smoking? Remember that tobacco is very addictive. A study by the Research Triangle
Institute showed that low-income smokers in New York, which had the nation's
highest state cigarette tax, spent nearly a quarter of their household income
on cigarettes. Nationally, those with the lowest incomes smoke less, but still
spend just over 14 percent.

In raising these issues, I
want to challenge my colleagues to think about how social class influences our
response to the unintended consequences of our liberal policies. In 1920, in
the face of rampant alcoholism, who could have imagined that prohibition would
cause alcohol-related mortality to soar out of control? But it did. But that
wasn’t the worst failure of public health at that time. The real failure was
refusing to support the repeal of prohibition once it was understood that the
law had made things worse. The public health community supported prohibition to
help people avoid the harms of excessive alcohol consumption, but couldn’t
change course even after it understood prohibition was making things
worse.

Yes, it bothers me that
Michigan’s Mackinac Center, which opposed the Affordable Care Act, also opposes
tobacco taxes. And I worry my musings may be mistaken when I see that my own
public health association, the Michigan Association for Local Public Health,
strongly supporting increased tobacco taxes. But we need to remember that real human
beings are the objects of our policy prescriptions. I remember meeting a low
income woman at a community event where Chantix, a drug that helps people quit,
was being distributed. She began crying. A tobacco cessation counselor hugged
her and said, “You’re afraid you won’t be able to quit” and the woman sobbed,
“I’ve tried so many times and nothing works.” I didn’t know people cried about
not being able to quit smoking until I saw it.

Think about this: it is
difficult to argue that we raise cigarette taxes because we really want to help
low income people quit, given that we do so little else to help them do so. If
we wanted to help people quit we would use the tax increases to address the
problems in people’s lives that keep them smoking. But we don’t. In Michigan we
have used tobacco tax revenue for things like scholarships, school aid and debt
service. I agree those things are important, but so little tobacco tax revenue
goes for smoking cessation in Michigan that the State gets a grade of F from the
American Lung Association for its paltry tobacco prevention efforts. The real
reason for the taxes is to plug budget holes, and we don’t lose sleep thinking
about the woman who spent her last dollar on cigarettes and doesn’t know what
she will eat tomorrow.

Thursday, January 5, 2017

A lot of times I ask my wife, Debra Bennett, among other
people, to read potential blog posts. Her comments help me communicate more
clearly. This time she told me this post
is too complicated, and I should concentrate on explaining to people, in clear simple
terms, how repeal of the Affordable Care Act would impact them directly. I
haven’t taken her advice and the reason for that is I want to use this blog,
not for simple advocacy, but to expose the real challenges faced by local
public health. There are probably 6,000
people working in local public health across the State and the purpose of this
blog is to show others what we see every day.
The vast majority of local public health departments are located in rural
parts of Michigan. These are places where heart disease mortality rates for low
income people are rising, where suicide and heroin overdoses are surging. Local
public health departments are madly trying to figure out what is happening and
what can be done about it. This is also
Trump country. We spend much of our time, whether it is talking about a
contaminated well or helping a mother get respite care for her handicapped
child, loving on people who decided to use their votes to “shake things up”, and
because of the election things are likely to get that much more difficult for everyone.
The details of this story are complicated and technical, and what I’m trying to
do here is let people see some of these details--details that are ordinarily
invisible to most people.

=======================================================

When Donald Trump was elected people became concerned that
the next Congress would repeal the Affordable Care Act (ACA or “Obamacare”).
However, some pundits reassured people that Congressional action would not be
too extreme. For example, well-informed commentators appeared on Politico’s Pulse Check
(It’s the episode entitled “Obamacare Endangered”) and said that while Congress
may repeal the ACA, it would actually retain important parts of it, because
Congress would not want to take away people’s health insurance, and because the
ACA is actually good for the health care industry.

But the incoming Congress is not behaving so
rationally. Now journalists are writing
that the next Congress is likely to repeal many of the most important and
beneficial parts of the law, including
the expansion of Medicaid. What does this mean for public health? Sure,
people will lose their health insurance, but that won’t impact local public
health directly, will it? Sure it will. Repeal of the ACA would unravel much of the
innovative work to strengthen preventive services that local public health has been
engaged in for the past six years. And
understanding this helps show how repeal of the ACA could literally be deadly
to those whose lives have been changed by it.

This isn’t just about protecting programs. Any time
legislatures attack health care or public health people get sick and even die
as a result. A contemporary example is what happened in Texas after their
legislature cut
funding for family planning services in 2011. You might be surprised that cutting family
planning funding could have a big, negative impact on health. In fact, family planning is counted among the
ten great public health
achievements because when women acquired the ability to control their
fertility both infant mortality and maternal mortality plunged. MMDHD is the
only public provider of family planning services in our three counties (Cherry
Health provides services to people for whom they are the primary care provider).
These services include comprehensive personal health services--not just birth
control—for people who might not be getting care anywhere else. The Texas
legislature cut funding for family planning in order to close down Planned
Parenthood clinics because some help women get abortions, and did not consider the
impact losing access to their other services would have on women’s health. As
soon as the funding cuts went through maternal mortality doubled!*

Yes, I am afraid Michigan could be facing something similar,
soon, not necessarily because of cuts to Planned Parenthood—the Michigan legislature
made a lot of noise about doing that only to discover Michigan gives no money
to Planned Parenthood—but because of the impact that repeal of the ACA could
have on public health.

There are three major ways that repeal of the ACA could
impact public health. The first would result if repeal leads to the elimination
of the Healthy Michigan Plan (expansion of Medicaid) or the Health Insurance
Marketplace (Healthcare.gov or “Obamacare”). More than 640,000 additional
people have gotten health insurance through Healthy Michigan and an additional
313,000 bought health insurance through the exchange. Nearly one million Michiganders will lose
health insurance if these plans are eliminated.

But it isn’t the loss of the ability to go to the doctor
that is the issue. The reality is that primary care doctors don’t necessarily do
a very good job of serving low income, vulnerable people who tend to have
complicated problems that extend beyond their specialty. Health insurance
enables these people to access other
preventive services such as mental health and substance abuse treatment,
smoking cessation and rehabilitation. Losing health insurance means people will
lose all this other stuff, too, and these services are the ones they really need
the most, that help them recover their health.

The second way that repeal of the ACA would impact public
health has to do with new, innovative
public health programs that have been stood up over the past six years
leveraging opportunities in the ACA which could be swept away. The ACA has
changed the environment in which providers of preventive services are operating
so that they are encouraged to create and experiment with new ways of finding
at-risk people and meeting their needs. Elsewhere I have written about
activities like the diabetes prevention program, co-location of mental health
and physical health services and community health workers (CHWs) which are
directly aimed at enabling the sickest and most vulnerable people to receive
services they need to recover their health. To provide just one concrete
example of how this has worked in Michigan, Medicaid health plans are now required
to support community health worker (CHW) programs. This requirement was enacted
as part of the Michigan’s State Innovation Model, its implementation of the
ACA. CHWs meet peoples’ non-medical needs (housing, food, transportation, etc.)
to get them to the point where they can begin to focus on health. For example, MMDHD
has created a CHW program that focuses on adults with chronic diseases. In Saginaw there is a CHW program that
focuses on people with mental health problems and Muskegon has a program for
women with risky pregnancies. Michigan’s CHW programs were evaluated and
shown to improve health outcomes and reduce costs, but our elected leaders may
decide that’s no reason to keep them around.

For an employer, writing on-line about the challenges your
operation is facing can be fraught. Yes it is good to try to attract attention
to potential threats. Maybe advocacy can change the outcome. But your employees
may read what you write and think “Oh my god! That’s my job he’s writing
about!” So to any MMDHD employees who read this, I want you to know we are
working on a Plan B (and C in fact) to sustain our programs in case the ACA is
repealed in a way that affects us.

The third way repeal of the ACA would affect public health
could result from the elimination of the Prevention and Public Health Fund
(PPHF). The PPHF is one of the best parts of the federal budget you never heard
about. It was established under the ACA to ensure that the ACA focused as
strongly on public health as on health care. Michigan has received nearly 100
million dollars from the fund which has been used for obesity reduction,
tobacco programs, heart disease prevention, cancer prevention and other
activities. Funds have gone to health
care systems, tribal governments, universities, community groups like YMCAs,
and yes, local public health. Unfortunately the fund has been embattled since
it was created and much less has been appropriated by Congress than was hoped
for. Nearly a billion dollars have been shifted from the PPHF to support
existing, inadequately funded CDC programs, too. This detail is important because it means the
fund is also supporting our existing, routine local public health programs (for
example family planning) through the CDC. If the PPHF was eliminated due to a
repeal of the ACA it would mean more than simply losing the special programs mentioned
above, but it could mean a reduction in local public health’s regular operating
budget.

So for example, suppose a million Michiganders lose their
health insurance and lose access to family planning services through their
primary care doctor. They might turn to
local public health for family planning as they did before the ACA. But just at that moment support for local
public health could be reduced because of elimination of the PPHF. This could be a real train wreck.

And don’t think Planned Parenthood will be there to fill the
gap. Legislatures that don’t fund that
organization and trying to shut them down by saddling them with bogus
regulations that make it too expensive for them to operate. Since Michigan
doesn’t fund Planned Parenthood there is no stream of dollars that could be shifted to
other providers, like local public health, if Planned Parenthood leaves the
State.

And we are only talking about the impact in one area: family planning! Now think about the impact across the suite
of programs local public health offers: communicable disease, outbreak
investigation, immunizations, WIC and home visiting programs, children’s
programs, hearing and vision programs, oral health, community health workers
and care coordination programs with mental health.

Could Michigan experience as spike in maternal mortality in
the near future? It’s something we need
to take very seriously, but it’s likely next time the damage will be spread
even further.

* The story of what happened in Texas is complicated.
Maternal mortality rates have been rising in many places in the United States,
not just Texas. One reason is that vital statistics agencies are getting better
at identifying cases of maternal mortality. Increases may also be linked to the
general
increase in mortality among low-income people that has been evident lately.
You should also know that Michigan is also, like Texas, a state with high
maternal mortality. Still the sudden, enormous jump in Texas is hard to explain
without understanding that many women lost access to family planning services
there.